Real-time tracking and virtual endoscopy in cone-beam CT-guided surgery of the sinuses and skull base in a cadaver model

Background: Custom software was developed to integrate intraoperative cone-beam computed tomography (CBCT) images with endoscopic video for surgical navigation and guidance. A cadaveric head was used to assess the accuracy and potential clinical utility of the following functionality: (1) real-time tracking of the endoscope in intraoperative 3-dimensional (3D) CBCT; (2) projecting an orthogonal reconstructed CBCT image, at or beyond the endoscope, which is parallel to the tip of the endoscope corresponding to the surgical plane; (3) virtual reality fusion of endoscopic video and 3D CBCT surface rendering; and (4) overlay of preoperatively defined contours of anatomical structures of interest. Methods: Anatomical landmarks were contoured in CBCT of a cadaveric head. An experienced endoscopic surgeon was oriented to the software and asked to rate the utility of the navigation software in carrying out predefined surgical tasks. Utility was evaluated using a rating scale for: (1) safely completing the task; and (2) potential for surgical training. Surgical tasks included: (1) uncinectomy; (2) ethmoidectomy; (3) sphenoidectomy/pituitary resection; and (4) clival resection. CBCT images were updated following each ablative task. Results: As a teaching tool, the software was evaluated as "very useful" for all surgical tasks. Regarding safety and task completion, the software was evaluated as "no advantage" for task (1), "minimal" for task (2), and "very useful" for tasks (3) and (4). Landmark identification for structures behind bone was "very useful" for both categories. Conclusion: The software increased surgical confidence in safely completing challenging ablative tasks by presenting real-time image guidance for highly complex ablative procedures. In addition, such technology offers a valuable teaching aid to surgeons in training.